The Secret

I hadn't noticed Frank’s son at first. He'd been pacing in the back of the family group gathered in our ICU waiting room. Now, up close, I could appreciate how large and intimidating he was. And I'd just had the thankless job of telling him, along with the rest of his family, a shocking, completely unexpected truth: Frank wasn't dying, he was already dead.

My first instinct was to look for an ally--someone to help me deal with this situation and reassure me that everything would be okay. I locked eyes with the hospital chaplain, the only one of my fellow healthcare-team members who was present.

She looked startled. I was only a second-year resident, and it was our first time working together. Amid the sea of family members, she was a lifesaver. Still, we were both at a loss for words.

Luckily Frank's daughter Louise spoke instead.

"Corey doesn't mean that; he's just hotheaded," she said. "You have to understand, our father walked in here last night with a cough, and now you're saying he's dead? We just can't accept that. And you keep saying that you don't know why he got sick. Can't you understand why we would be mad?"

Up to this point, all of my training and practice discussions had helped.

Before breaking the news, I'd done my best to set the stage: "As you know, your father came into the ICU last night, and he’s been very sick. Is now a good time to talk? Would you like anyone else present?"

I'd invited the family to share their knowledge of the situation: "Can you please tell me your understanding of what’s been happening?"

You name it, I did it (I think). But now we were in uncharted territory--and I did understand their frustration. If this were my father, I would be furious too. Who screwed up? would be my first thought. Even if I were told there was no error--and there had been none here--I'm not sure that I would believe it, either.

I wished that I could say what I really felt: "I'm angry too. I showed up this morning and ran the code on your father. It was the first time I'd ever seen him, and my first code blue ever. It lasted for more than an hour--and we couldn't save him. And now I've been tasked with telling you this because the ICU team has so many other patients to see."

I wanted to go deeper--to spill my angst and misgivings about residency: "It feels terrible that my life as a resident is more about paperwork than it is about patient care. And the paperwork and documentation are one reason the rest of the team isn’t here with me now."

I wanted to say, "I know that I can't fully understand what it must feel like for you, as African-Americans, to hear this terrible news delivered by a white man, but I want you to know that your father was treated with respect and kindness by our hospital staff, who are very diverse, racially and ethnically. And I want you to know that the chaplain and I feel frightened by what you just said, because someone recently shot a doctor in Boston whom he blamed for his mother's death, so I'm struggling over whether I should call hospital security."

Most of all, I wanted to break the promise my team had made to Frank, in response to his dying request: that we would not tell his family what his illness was, and how sick he'd really been before he came into the hospital.

I felt horrible. Sick to my stomach. I'd never even spoken directly to Frank--but I had to keep his secret.

If only I could tell them, if I could give them some hint as to how hard this is, they might understand, I thought. Then maybe we won’t have to call security, and I won’t have to worry about walking home alone tonight.

Instead, I stuck to my training.

"I am very sorry for your loss," I said. "I know that you want to see him. We can go whenever you're ready."

Frank's family filed into his bedside. They cried, they mourned, they supported each other. Our chaplain and nurses were incredible in helping them through the process. Later we talked again, and some thanked me for being there. Corey, clearly devastated, remained quiet throughout the rest of the afternoon. I realized that my imagined outburst, however truthful, would only have made things worse all round, and especially for him.

To this day, I think about Frank, about his secret illness, and about his family. I still feel for them--for their loss, and for the pain of the questions that we just could not answer. I hope that, by now, they've healed as best as they can.

At one of the most stressful points in my career, I chose to honor a dying man’s wish at the expense of his living relatives. Ultimately, they requested an autopsy, and Frank’s potentially stigmatizing illness was revealed. It was a relief to know that they'd learned the truth, but also that I had stuck to what I believed was right.

Even now, I struggle with the ethical dilemma of honoring the dead’s wishes at the expense of the living. But as doctors, I believe, we are bound to protect our patients both before and after their passing.

There are things you can't learn in medical school, no matter how much you study. One is knowing when to say, "I don't know." Another is knowing when not to say what you do know.

About the author:

Originally from Florida, Gabriel Foster is a senior medical resident at Beth Israel Deaconess Medical Center, in Boston. "I first became interested in writing during high-school English class. Later, I came very close to completing a minor in creative writing at Dartmouth College, but instead dropped it in favor of a third foreign language." He is currently working on his first novel.

Comments

If criminal cause is not suspected in a death in many cases the family has to pay for the autopsy, which can be substantial. Of course, that is above and beyond the emotional stress of the episode, and The Cause - the family did not trust what you said or what you did.My path would have been to tell them-"Your father asked us not to share any of his medical information with you. However, by federal law a family member has the right to a copy of his medical records. ____ from our hospital can assist you in that process.It will answer your questions about how and why he died".

simply the law, not what I "believe"-http://www.hhs.gov/hipaa/for-individuals/personal-representatives/index.html

I am sorry, but bedside death wishes or promises die when the patient dies and the family becomes your unit of care. Just like a parent dying makes a child promise they will "never" put the surviving spouse into an ECF, it is done to relieve the dying person's anxiety, but you are not held to that promise might in duress. If that family had not had an autopsy done, they would never know the truth and it would haunt them for the rest of their lives. It prolonged their grief process and disrupted the trust relationship you needed to develop to help them thru this life changing event. Telling the truth wins out over a lie in most circumstances and not telling the truth did not hurt the dead, only the living.

Delivering these types of news is not an easy task. I have been in practice for 22 years and still feel unconftable when I have to do it. I see two issues that are worth mentioning: racial/ethnicity perceptions and keeping information from the family.I have the best relationship with all my patients, african americans are no exception and If you sit with a patient or family you can achieve a lot. Unfortunately, the resident did not had that opportunity since it seems that he just started the say. That is not fair although not uncommon these days with 80 hour work rules in training. To avoid this issue as soln as the situation allows there should be a discussion with family covering expectations.The resident felt intimidated and it is a natural reaction when you get a message like that nonmatter who is it coming from. For the resident the best thing to do is to remain professional, not antagonize and best of all be a human and empatize.

Only the intern knew that the dead man had asked him not to reveal to his family that he knew he was dying when he entered the hospital. To "honor" the dying man's wish when the doctor knew he could diminish the suffering of his family by telling them the truth seems to me a perversion of the idea of honor. The doctor sacrificed the family to avoid his own pain.

As a retired academic pediatric intensivist, I am forever amazed that our teaching standards would place a second-year resident in the position you described, and did so so vividly. Why would the attending physician not be the bearer of such news? A resident, participating in the discussion, might learn valuable communication skills, presuming of course that the attending had honed his/her own communication skills over the years. In any event, nicely written.

"..I can't fully understand what it must feel like for you, as African-Americans, to hear this terrible news delivered by a white man, but I want you to know that your father was treated with respect and kindness by our hospital staff..And I want you to know that the chaplain and I feel frightened by what you just said, because someone recently shot a doctor in Boston whom he blamed for his mother's death, so I'm struggling over whether I should call hospital security."Gabriel, thank you for your story, especially in a time where the term "political correctness" has taken on new meaning! I am a Black woman and a nurse who recently and unexpectedly lost my mother. I am from a large family and I can see how an ill-placed, emotionally charged phrase can be taken literally. Although you certainly cannot speak for the masses, I appreciate your honesty as it relates to preconceived fear of Black men in stressful situations. I will share your story with my class Monday.